Have you been worried about an older person’s memory or thinking abilities?

Maybe your parent has seemed more confused recently. Or you may have noticed that your aging spouse is repeating herself, or struggling to do things that didn’t use to pose much of a problem.

These are very common concerns, and they often lead to questions such as:

Is this normal aging or something more significant?

What is wrong?

Could this be Alzheimer’s? Or some other form of dementia?

Can this be treated or reversed?

What should we do about this??

The answer to the last question is this: if you are worried about memory or thinking, then you should seek out some kind of medical evaluation.

That’s because when families worry about an older person’s cognitive abilities, there often are some underlying health issues affecting the mind’s function.

Those need to be detected, and treated if at all possible. So, you’ll need to request help from a health professional, and in this article, I’ll explain what that initial help should consist of. This way you’ll know what to expect, and what the doctor might ask you about.

Technically, these kinds of problems are called “cognitive impairment.” This is a broad term that means some kind of problem or difficulty with one’s memory, thinking, concentration, and other functions of the conscious brain, beyond what might be expected due to normal “cognitive aging.”

Cognitive impairment — which is also called “cognitive decline” — can come on suddenly or gradually, and can be temporary or more permanent. It may or may not keep getting slowly worse; it all depends on the underlying cause or causes.

In this article, I’ll share with you the more common causes of cognitive impairment in older adults.

I’ll then share a list of 10 things that should generally be done, during a preliminary medical evaluation for cognitive decline in an older adult.

Common causes of cognitive impairment in older adults

Cognitive impairment, like many problems in older adults, is often “multifactorial.” This means that the difficulties with memory, thinking, or other brain processes are often due to more than one cause.

The more common neurodegenerative conditions include Alzheimer’s disease, Lewy-Body disease, Parkinson’s disease, and frontotemporal degeneration.

Infections.

This is not as common in older adults as the other causes above, but certain chronic or acute infections can affect brain cells directly. (If cognitive impairment is caused by an infection outside the brain, such as pneumonia or a urinary tract infection, this would be considered delirium.)

Toxins are another potential cause of cognitive impairment. Research is ongoing as to the cognitive effects of toxins people may be exposed to, such as heavy metals, air pollutants, contaminants in our drinking water, pesticides, and others.

Now that I’ve covered the most common causes of cognitive impairment in older adults, here’s what an initial medical evaluation should generally cover.

10 Things the Doctor Should Do When Evaluating Cognitive Impairment in an Older Adult

Here are ten specific things the clinician should ask about, check on, or do, as part of an initial evaluation for cognitive impairment in an older adult.

The following list reflects my own practice and that of most geriatricians. It is in line with most syntheses of guidelines and best practices, including the UpToDate.com chapter on this subject.

Most experts agree that these steps can be done by primary care clinicians.

1. Ask about and document the patient’s concerns about memory and thinking.

At a minimum, the clinician should ask an older person something like “So, have you noticed any changes in your memory or thinking abilities?”

Now, many older adults will either have noticed nothing or won’t want to talk about it. This in of itself is worth noting, especially if family or others have voiced concerned.

If the older person does have concerns or observations, these should be explored. It’s especially important to ask when the problems started, and whether they seem to be getting worse, and how quickly things seem to be changing.

2. Obtain or request information on memory or thinking difficulties from family members or other “informants.”

Older adults with cognitive impairment are often unaware of — or reluctant to reveal – the difficulties they are experiencing. For this reason, a health provider who has been alerted to the possibility of cognitive impairment should make an effort to get information from a family member or other knowledgeable informant.

It’s sometimes necessary for the health provider to be diplomatic about requesting and getting information from family members, especially if the older person finds it upsetting. People may think that HIPAA doesn’t allow doctors to talk to family over an older person’s objections, but actually, clinicians do have some leeway in these situations. (See my HIPAA article here.)

Family members can facilitate this process by bringing in a written summary of what difficulties they’ve observed. Be sure to include information on when the problems started and whether they seem to be getting worse.

3. Ask about difficulties managing instrumental activities of daily living (IADLs) and activities of daily living (ADLs).

The ideal is to for the health provider to ask both the patient and the family about this. Older adults with cognitive impairment are often not reliable reporters of what difficulties they’re having.

Instrumental activities of daily living (IADLs), in particular, are often affected by cognitive impairment. So it’s important to ask if the older person is having difficulty with problems with tasks such as:

Driving and other forms of transportation

Management of finances

Grocery shopping and meal preparation

Home maintenance

Managing the telephone, the mail, and other forms of communication

Medication management

The provider should also ask about ADLs, which are the more fundamental self-care tasks such as walking around, feeding oneself, getting dressed, managing continence, and so forth.

Difficulties with IADLs and ADLs (which geriatricians refer to as “functional impairment”) are important to document. They offer a practical lens on how “severe” an older person’s cognitive impairment might be, and on what steps could be taken to support an older person while these cognitive issues are getting evaluated.

Functional impairments may correspond with safety issues that need to be addressed; if an older person is having difficulty with finances, it may be a good idea to check for signs of financial exploitation, or otherwise take steps to protect the person financially.

Last but not least, impairment in daily functioning is also a criterion that separates mild cognitive impairment(MCI) from more significant impairment (including dementia). In MCI, a person may be experiencing some cognitive impairment, but it should not be bad enough to significantly interfere with performing daily life tasks.

4. Check for the presence of other behavioral, mood, and thinking symptoms that may be related to certain causes of cognitive impairment.

These include:

Hallucinations

Delusions

Personality changes

Apathy (losing motivation)

Depression symptoms

Anxiety symptoms

Getting lost

Confusion about visual-spatial tasks (e.g. having difficulty figuring out how to put on one’s shirt)

5. Ask about any new symptoms or changes in physical health.

It’s especially important to ask about symptoms related to neurological function, such as new difficulties with walking, balance, speech, and coordination. Checking for tremor and stiffness (both of which are associated with Parkinsonism) is also recommended.

The exact questions the clinician asks will depend on the person’s particular medical history, and the other signs and symptoms that have been brought up.

6. Ask about substance use and consider the possibility of substance abuse and/or withdrawal.

Excessive use of alcohol, certain prescription drugs (such as tranquilizers), or of illicit drugs can affect cognitive function. Health providers should inquire about an older person’s use of these substances.

Suddenly stopping or reducing the use of alcohol or other substances can also occasionally cause or worsen cognitive function.

7. Review all medications, with a focus on identifying those known to worsen cognitive function.

Certain types of medications tend to dampen brain function, and may cause a noticeable worsening in cognitive abilities. The health provider should especially ask about use of:

Benzodiazepines, which are often prescribed for either insomnia or anxiety

At a minimum, the health provider should check vitals (blood pressure and pulse) and should also complete a basic neurological evaluation, including an observation of the person’s gait, balance, and coordination.

The purpose of the physical exam is to look for physical signs that may correspond to causes of cognitive impairment, or that may relate to other symptoms the patient or family brought up.

9. Assess the person’s orientation and perform some type of office-based cognitive test.

Assessing “orientation” means checking to see whether the patient knows things like the day, date, month, year, and where he or she is.

Some office-based testing should also be done, to check and document the older person’s memory and thinking abilities.

Probably the shortest well-validated test is the Mini-Cog, which involves a three-item recall and a clock draw.

A more detailed office-based cognitive test that can be done in primary care is the MOCA test (Montreal Cognitive Assessment Test). This takes 10-20 minutes to administer, so it often requires scheduling a separate visit.

There are some other “intermediate” length tests that can be done in the primary care office, such as the SLUMS (St. Louis University Mental Status Examination). The Mini-Mental State Exam is another option, although most experts (including myself) consider it less useful than the MOCA or SLUMS.

As for brain imaging, some expert guidelines recommend it for everyone and other guidelines suggest it be used “selectively.”

(In most cases, brain imaging reveals non-specific findings such as signs of cerebral small vessel disease and perhaps some mild atrophy of the brain. These are common findings in many older adults and tend to have a variable correlation with symptoms. Most causes of cognitive impairment cannot be definitely ruled in or ruled out by brain imaging.)

In Summary

Overall, an initial medical evaluation should result in these four key things happening:

Documentation of the patient’s and family’s cognitive concerns.

This means documenting what the patient and family have noticed, in terms of difficulties and changes in memory, thinking, behavior, or personality.

Documentation of any functional impairment the older person is experiencing.

This means documenting what the patient and family have noticed, in terms of difficulties managing life tasks (IADLs and ADLs).

An objective assessment of the older person’s memory and thinking skills.

This is done through some form of standardized office-based test.

Clinicians can also document their impressions and observations based on talking to the older person. (Did the person seem confused? Paranoid? Repetitive? Tangential? Was the person able to answer detailed questions?)

An evaluation for common medical causes and contributors of cognitive impairment.

This means checking for those common problems that can cause or worsen cognitive impairment.

Generally, it will take at least two primary care visits to complete an evaluation for cognitive impairment.

The second visit is often used to do a cognitive test such as the MOCA, and can enable the clinician to follow up on laboratory tests that were initially ordered.

And then what?

Well, what happens next depends on several things, such as:

Whether the health provider was able to draw conclusions about what is likely causing the cognitive impairment

Whether treatable conditions were identified

How the patient and family feel about the evaluation

Whether the older person is willing and able to cooperate

Whether the clinician feels that referral to a specialist is necessary

Whether the clinician is willing and able to help the older person and the family (or refer them for help) addressing any functional impairment or safety issues

You may be wondering: should you expect a diagnosis or “an answer” after this evaluation?

I’ll be honest here: probably not. Even with an adequate initial evaluation, cognitive impairment may take a few months (or even longer) to completely evaluate and diagnose. For instance, it’s often necessary to try treating one or more potential causes, to see if the cognitive problems improve or not.

Other causes of cognitive decline — notably neurodegenerative conditions such as Alzheimer’s and some of the other dementias — can take a while to diagnose because clinicians are first supposed to exclude the other potential causes, and that can take a while. (For more on the diagnosis of dementia, see “How We Diagnose Dementia: The Practical Basics to Know.)

What to expect from an initial evaluation for cognitive decline

It may not be realistic to expect definite answers. But that doesn’t mean you can’t expect some explanations.

Your health provider should be able to explain

How substantial the cognitive impairment appears to be, based on the office-based testing and the evaluation so far,

What was checked for, and what has been ruled out (or deemed unlikely) as a cause for the problems you’ve been worried about,

Whether any of the medications might be making memory or thinking worse, and what the options are for stopping or reducing those medications,

What the healthcare team proposes to do next, to further evaluate the issues or follow up on the problems.

So if you’ve been worried about memory or thinking problems, ask for that medical evaluation. If your health provider skips any of the steps I listed, don’t be shy and ask about it. (Either it’s an oversight or they should be able to explain why it’s not necessary.)

You probably won’t get all the answers and certainty that you’re hoping for, but you’ll have gotten started and that’s vitally important.

Of course, you may well be facing the problem of not being able to get your older loved one to go to the doctor. That’s an issue I’ll have to write another article about.

In the meantime, especially if it’s a challenge to see the doctor for some reason, then it’s all the more important to the most out of your medical evaluation when you do manage to get there.

Do you have any questions about the initial medical evaluation for cognitive impairment? Please post them below.

Even if the physician has limitations as to what he can reveal to family members over the patient ‘s objection, there is no limitation on what family members can tell the physician. They are free to tell what they have observed.

I do think the ideal is for the older person to be aware of and agreeable to a family member communicating with the doctor. If this seems upsetting to the older person, then family members can consider how to go about being more discreet. Options include contacting the doctor beforehand, or simply discreetly mentioning to the medical assistant in clinic that you have something to mention privately to the doctor. I do recommend putting concerns in writing, so that they can be added to the chart.

Now sometimes older adults will actually forbid their family to contact the doctor. This puts the family in a tough spot. It is still legal for them to contact the clinician, and if they are seriously concerned and there is no other way to alert the clinician, then the benefits of disregarding the older person’s preference might be worth it.

Perhaps the very best would be for every older person to talk to their family well ahead of time, about what to do if the older person ever becomes cognitively impaired and is refusing medical (or other) assistance.

We could certainly question the “competence” of some health professionals, but I would say the bigger problem is that they are usually busy and distracted.

Doing the actual steps is not that difficult (with the possible exception of administering the MOCA), it’s thinking of them and following through on them which is the challenge. Everything other than an intermediate-length office-based cognitive test could be done in a single visit. Especially if the patient and/or family come prepared with all the medications (including over-the-counter ones) in a bag, plus a list of observations re cognitive difficulties and functional difficulties.

It also helps for the older person to be accompanied by a family member for the visit, if possible.

Good article…I shared with my adult children to help them from jumping to ill-founded conclusions…but also what to be aware of.

Article also reminded me of the difficulty I had in getting a ‘definitive’ diagnosis for my aging mother 8 years ago. For some legal and financial issues a diagnosis of ‘cognitive impairment’ is necessary.

Yes, as you point out, a diagnosis often is necessary for legal and financial issues. A diagnosis — or even evidence of some cognitive impairment — should also prompt the medical team to reconsider some of what they are doing.

How to get a “definitive” diagnosis could be an article in of itself. The first step is to get the ball rolling with an initial eval and hopefully to not get too much of a run around.

Two problems I have encountered are:
Finding a PCP willing to do a complete physical exam. I had one PCP who once didn’t look at my concern about my legs swelling. Too often they just refer a patient to a Specialist. Then they refer you to another one.
I live by myself, have no living or trusting relatives, and just a few friends. So, I don’t really have anyone
who a doctor can ask questions about my behavior. Please consider seniors who are aging alone.
This was a very informative article. Thank you.

Thank you for sharing these comments. Yes, PCP are often rushed or for other reasons, they are not as attentive to the patient’s concerns as we would like them to be.

Aging without the support of relatives certainly poses additional challenges…I’m still trying to determine what is useful advice to give, in terms of planning ahead to minimize problems and get help if cognitive impairment should become an issue. We want to hope for the best but it’s also a good idea to plan for things that well might happen.

There are some groups springing up online (and perhaps also in-person) of older people who are “solo agers”, in which people exchange ideas. You could see how others are tackling this type of issue. Good luck!

Some time ago, I wrote about a relative with memory problems. Twice now I have called and said that there are memory problems prior to scheduling checkup appointments. And twice my relative has proudly outwitted the doctor! Second visit doctor said that I had suggested there was a problem – I took some abuse without knowing the cause until just recently!! This third visit I said nothing, and my relative breezed through the exam and was declared perfectly healthy!!! Sheesh! I give up and I’m going to make an appointment with a counselor about all the problems my relative is causing in my life. I understand Harvard Medical has discovered that about 40% of potential dementia patients are smart enough to outwit these tests! I believe it! P.S. Thanks so much for the heads up on Smart Patients – their help and support got me through sarcoma cancer.

Unfortuantely, this kind of thing does happen. Sometimes the older person really does have minor deficits, but in other cases, the clinician is not being thorough enough or attentive enough.

I think it’s an excellent idea to get some support and counseling to help you cope with any caregiving stress. There are also online caregiving forums, such as the one at AgingCare.com, and those can be helpful for moral support. Good luck and take care!

My question is related to cognitive testing and the interpretation of results. At what point, is a senior considered unable to make medical decisions? At what point is a HCPOA activated? My father is living in a nursing home and the medical director deactivated his HCPOA. However, my loved one is testing as severely impaired with a score of 1.4 out of 4.0 on repeat Cognitive Linguistic Quick Test administered by the nursing home’s own Speech Therapist. However, the therapies cannot officially weigh-in on HCPOA status. The facility refuses to reactivate his HCPOA even when faced with the evidence. They are taking advantage of him by having him attend care meetings without family and signing paperwork without family present too. They say he is his own person, but my father doesn’t know where he is living, what he owns, or who in his life is dead or alive. It takes two doctors to activate a HCPOA but only one negligent doctor to deactivate it.

Interesting issue you are raising! Hm…well, a durable power of attorney for healthcare (DPOAH) often will specify whether the agent’s authority is effective immediately versus only when the principal (the person signing the form) is deemed incapacitated. Even if the agent has authority immediately, if the agent and principal disagree, the principal gets to decide, unless the principal is incapacitated.

Incapacity does sometimes reverse. Honestly, I don’t often hear about physicians “deactivating” an agent’s authority but it could be reasonable under certain circumstances. (Not at all clear it was reasonable for them to do so under the circumstances you describe.)

It sounds like the nursing home decided that your father currently has the capacity to make his medical decisions, and so they are relying on him to participate in care meetings rather than involving you, his healthcare proxy.

Capacity to make decisions is technically specific for the decision (some are much less complicated or high-stakes than others) and also can change depending on a person’s health and state of mind. That said, as dementia progresses, people lose their decision-making capacities and so we usually stop assessing it for every single decision at some point, when they’ve reached moderate stage or beyond.

If your father doesn’t know where he is living or what he owns, it would be unusual for him to still be able to comprehend and make medical decisions, so you’re probably right to be concerned.

The issue for you will be figuring out an effective way to intervene. Your options include:
– check your state’s laws (they are usually available and searchable online) regarding power of attorney and capacity, there may be something relevant to the situation you describe, in terms of who decides incapacity or under what conditions a previously authorized agent can be kept out of the proceedings.

– Write letters to the nursing home outlinining your concerns and the reasons why you believe he does not have the capacity to meaningfully participate in the care meetings. If you look like you understand what capacity involves, this might impress them. I have some information on capacity here: Incompetence & Losing Capacity: Answers to 7 FAQs

– Get another medical professional to assess your father’s capacity to participate in his decisions without you. A generalist physician should be able to do this, especially if you bring in enough information about your father’s past medical history and how long he has been impaired. You can also sometimes hire a clinician to go into the nursing home and see him. There are also some patient advocates who are doctors or other clinicians qualified to render an opinion on capacity.

– Talk to an elderlaw attorney. They will know the relevant laws and your options for challenging the nursing home’s decision.

In general, POA documents are regulated by state laws and I think most states don’t have very good provisions or guidance in place regarding assessing capacity and when an agent should and shouldn’t be involved.
Good luck!

Do you think it makes sense for doctors to conduct routine cognitive function screening of all patients at a certain age, e.g., 90? My dad’s physician saw him regularly but never checked how his brain was functioning. He checked his BP, blood work, an occasional viral illness or infection, and physical aches and pains, but that was it. My mom had been taking him there but was no help, since she was in denial that anything was wrong. When I finally took my dad (at age 93) to his doctor and provided a list of behaviors that had changed significantly over recent years, the doctor administered a mini-mental test. My dad scored 16 out of 30. I believe he had Alzheimer’s type dementia for at least a decade before this, but his doctor had no idea. Shouldn’t this have been detected earlier?

Yes, ideally his impairments would have been detected earlier. Unfortunately quite a lot of research indicates that older adults with impairment and even frank dementia are often not assessed or diagnosed by their usual physicians.

There are a lot of reasons for this which I won’t go into now, suffice to say that it’s not safe to assume that the doctor will notice or address cognitive impairment. This is one of many ongoing quality and safety issues relevant to the healthcare of older adults.

In terms of whether doctors should screen: the US Preventive Services Task Force reviewed this question a few years ago and concluded that the evidence was insufficient to make a recommendation. Cognitive Impairment in Older Adults: Screening

Now that question was whether to screen all adults aged 65+ (i.e. Medicare beneficiaries). Technically screening means checking for disease or illness before symptoms become apparent, so evaluating someone who is having some difficulties is not the same thing, that’s doing an initial evaluation.

In geriatrics we believe it’s especially important to screen (meaning to ask everyone) about functional difficulties. If there are problems with IADLs then we are quick to consider cognitive impairment.

Cognitive screening IS supposed to be included as part of the Medicare annual wellness visit (AWV), but it’s not clear to me that most older adults are being offered the AWV, or that it’s being done thoroughly when it is done.

Generally a medical clinic that is specifically designed to care for older adults will do a better job of detecting these problems, compared to a general primary care office.

In short, much work remains to be done. Until the medical system is better at addressing this, we must keep encouraging family members to speak up and be proactive.

Your information is most helpful, clear and caring. As someone who has lost a parent, friends and other family members to various types of dementia, and now my husband has been diagnosed, I know how stressful and exhausting this disease can be for caregivers.

I live in a small town and the attitude of most GPs is that dementia can’t be “cured”, so there is not much they can do. However, they overlook the families and friends who are trying to help the patient. With all the information out there on the types of dementia, doctors need to make more effort to determine the type/cause of the dementias so caregivers can research what they will be dealing with as the disease progresses.

Your recommendation to find a support group is spot on! Talking with others who are going through the same thing, or have been there, will provide you with information you will not get from a doctor. Plus you will make friends who will understand, support and advise you through the various stages, and grieve with you as your loved one declines whether through dementia or a physical condition.

Glad you found the article helpful and thank you for sharing these insights.

Yes, dementia generally can’t be “cured” but there is always IS quite a lot that can be done, and it’s unfortunate that many GPs don’t realize this. It certainly is important to support and educate the person’s caregivers, and then often there are some things that can be done medically, to optimize person’s brain function and help them be at their best despite the underlying changes to the brain.

I do wish more people would find support groups, thank you for bringing this up!

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